Non Ulcer Dyspepsia

Introduction

Upset stomach or occasional heartburn may not be due to excess stomach acid but there are several OTC medications available to reduce stomach acid and apparently solve the problem. What are the options a person has when they have an upset stomach or NUD (non-ulcer dyspepsia) due to eating? Is there one problem or many? Should the treatment be the same for each person or should it depend upon the person? Are medications ever necessary? With the heavy promotion of antacids and many other medications for heartburn and indigestion, many people may not know that there are other choices for these very common problems. First a look at the problem from the Western point of view, both mainstream and non-drug approach and then the Ayurvedic view.
NUD is upper abdominal pain without an ulcer, which is twice as common as an ulcer and may lead to one. In half of the cases of NUD or indigestion no cause is found, but medication is commonly used to control symptoms. Allopathic medicine is focused on organic damage and may over look function of the GI tract. The gastrointestinal tract is a very integrated system via nervous and hormonal regulation, and all medications have side effects of disruption or turning off some of the GI function. There is poor understanding of NUD and consequently no specific care from standard medical treatment. NUD can resemble GERD, ulcers, gastritis, or hiatal hernia but if there is no cause or damage found it is called NUD or functional dyspepsia, or just plain indigestion with no apparent treatment. The symptoms are similar for each condition: dull ache, uncomfortable fullness, or static stomach, distention, overt pain or burning or both with or without nausea. Excess stomach acid is not thought to be the problem, more likely inadequate protection of the stomach from the acid. The symptoms may also be due to slower gastric motility or to increased gut sensitivity.
Psychological issues also affect NUD. Stressful events produce responses in the gut, but people with NUD do not seem to have more stress in their lives than those without NUD. Do those with NUD react more strongly to stress leading to symptoms? Relaxation techniques have been shown to reduce gastric acid secretions in hyperchlorhydric patients. Balancing digestive function by reducing stress maybe partially attributed to a global nervous system shift from a sympathetic to a parasympathetic tone (1).
Diet involvement in NUD is important but not well defined. Certain foods and other substances are known to increase symptoms; spicy, acidic, and high fat foods, alcohol, tobacco, coffee, analgesics and other medications. These are reduced or eliminated to help with symptoms.
In a functional approach to health and nutrition diet and eating habits play a more important role than the standard allopathic model. The following is a functional view of digestion.
Digestion begins with the cephalic phase in which any sensory stimulus or even thoughts can provoke a digestive related response in the body. These include thermodynamic, salivary, cardiac, mesenteric blood flow, diuretic, digestive enzyme secretion, altered gastric acid secretion, altered intestinal motility, release of GI hormones and other intestinal process changes (2). Impulses travel via the vagus nerve to the stomach where acetylcholine stimulates mucus, acid, and pepsinogen secretion in the body and gastrin release in the antrum. The response is greater to foods that the person likes and is less in bland foods, an important fact with an anorectic client (3). To fully support digestion eating in a calm manner and chewing properly are necessary. For some this may be more helpful than relying on digestive enzymes, glandulars, bitters, or other digestive aids.
In the mouth or lingual phase adequate salivary output is necessary for proper digestion. Besides enzymes like alpha amylase the saliva also contains other important substances such as mucopolysacirides, ion containing fluids, and transcobalamin III necessary for vitamin B12 absorption. The digestion of fats is initiated in the month by lingual lipase from glands at the base of the tongue. Lingual lipase hydrolysis short chain and medium chain triglycerides more readily than it does long chain triglycerides. This is also true of gastric lipase. Both lipases are resistant to the proteolytic enzymes and the acid environment of the stomach,so that the digestion of the short and medium chain triglycerides continues in the stomach, but the main digestion of fats is done in the small intestine. Dehydration can reduce salivary output as can old age and thus reduce the digestive response.
Digestion in the stomach results from proper coordination of hydrochloric acid and pepsin along with other substances. Gastrin and intrinsic factor are the other two compounds that are exclusively produces in the stomach. In the gastric phase stimulation of secretions is by direct contact with food, a rise in ph, and by distention or mechanoreceptors. Besides the main job of digesting protein foods, appropriate amount of hydrochloric acid is necessary for:
The absorption of minerals.
Acid-base balance.
To kill microorganisms.
Converts pepsinogen to pepsin (at ~ ph of 2).
Inhibits the secretion of gastrin.
And stimulates the secretion of secretin.
Gastrin stimulates the secretion of acid and pepsinogen, increases gastric blood flow, circular muscle contractions in the stomach, and growth of the mucosa of the stomach and small intestine. Thus there are not only many coordinated responses to food for adequate secretions and proper digestion, but also feedback systems to down regulate the secretions when they are no longer needed. Mixing of the stomach contents is from the middle of the stomach toward the duodenum. This mixing, with downward pressure from the upper part of the stomach, help to empty the contents. The time required to empty the stomach depends on several factors. Solids, lipids, and solutions of high osmotic pressure empty more slowly than solutions that are isotonic. Solids empty more slowly than liquids. There are receptors in the duodenum that respond to lipid content, acidity, and osmotic pressure of the chyme. Some of the factors involved in the emptying are gastrointestinal hormones and neurological reflexes. The enterogastric reflex inhibits peristalsis in the antrum, which is next to the duodenum, because of high or low osmotic pressure, or when acidity is high in the duodenum. Particle size, viscosity of the chyme, and volume of the gastric contents also affects emptying time (4). Emotional stress affects motility through the autonomic nervous system.
Hypochlorhydria – inadequate secretion of gastric acid by the parietal cells in the stomach wall is a component of poor digestion. A diet of excess protein increases acid production and high fat diet encourages over secretion of acid. Medications to reduce acid, H2 histamine receptor blockers and proton pump inhibitors are now available OTC so that diet induced hyper acidity becomes medication induced hypoacidity in many U.S. adults with causes of indigestion not explored. Research suggests that low gastric acidity may influence the development of diseases such as:

• Rheumatoid arthritis
• Acne rosacea
• Celiac disease
• Diabetes mellitus
• Eczema
• Hepatitis
• Asthma and others (5).

The ability to produce acid decreases with age and over half the population over 60 has insufficient secretory ability. Common sign and symptoms of low gastric acidity are:

• Bloating, belching, burning, and flatulence immediately after meals
• A sense of fullness after meals
• Indigestion, diarrhea, or constipation
• Mild food allergies
• Undigested food in the stool
• Post adolescent acne
• Nausea after taking supplements
• And other sysmptoms
• Chronic reduction of gastric acid secretion invites bacterial over growth in the stomach
  

(Heliobacter pylori) and the small intestine which compromises nutrient digestion and absorption especially B vitamins , iron, and calcium. H. pylori does not appear to cause ulcers but let untreated may lead to atrophic gastritis (6). I f gastritis progresses to an ulcer then H. pylori has to be addressed usually with acid controlling medication and antibiotics.
In the treatment of NUD it is recognized in allopathic medicine that there is no reason for medication but it is often given because of its placebo effect and the drugs are considered safe. Though excess acid may not be the problem in the short term some people feel better with medication to reduce acid or to increase the rate of stomach emptying (7). Treatment also requires dietary and lifestyle changes to reduce symptoms. First a look at the medications then the diet and other changes.
Drugs that were developed for ulcer treatment are now being used for any problem that manifests itself as acid indigestion even if there is no known ulcer. The following are the drugs commonly used:

• Antacids are used to neutralize acid: Those with aluminum can cause constipation, those with magnesium can cause diarrhea, prelief (calcium glycerophosphate) is taken at meals to reduce stomach acid. H2 histamine receptor blockers to reduce acid secretion from the parietal cells, via histamine release stimulated by the vagus nerve. This includes Tagamet, Pepsid, Axid, and Zantac.
• The proton pump inhibitors: Previcid, Prilosec, Nexium, Aciphex, and Protonix that are so heavily advertised today, and are in use more now than the H2 histamine receptor blockers.
• Motility agents that speed up gastric emptying and increase lower esophageal sphincter (LES) pressure. Reglan, and Propulsid.
• And protective type drugs: Cytotec, Arthrotec, and Carafate (8).

In the case of an infection or apparent infection of H. pylori the common medication of Pepto-Bismol has been shown to be affective with a usual four times a day dosage over two weeks with less side effects than the typical drug and antibiotic therapy (9). The possible side effects of these medications are numerous, as listed below (10).
<="" b=""> that turn off stomach acid secretions, like Prilosec and Prevacid: Diarrhea, abdominal pain, nausea, vomiting, heartburn, liver necrosis, pancreatitis, Headaches, back pain, anemia, infections, and others.
Gastric motility drugs like Propulsid and Reglan: Ventricular tachycardia, and fibrillation, headache, diarrhea, abdominal pain, nausea, constipation, joint aches.
Cytoprotective agents like Cytotec that increase bicarbonate and mucus production: Nausea, vomiting, gas, heartburn, diarrhea, constipation, abdominal pain, abortion, Menstrual irregularities, headaches, depression, impotence, chest pain, arrythmia, High blood pressure, blood clots, GI bleed, liver malfunction and others.
Stomach coating medication for protection from acid like Carafate: Diarrhea, nausea, vomiting, dry mouth, turns off pepsin , and contains Aluminum, which has possible links to Alzheimer's disease and bone loss.
H2 blockers – Tagamet, Zantec, Pepcid, Axid, Mylanta – which turn down acid production: Impair liver detoxification processes thus increase the side effects of other drugs and environmental chemicals that use the same detoxification pathways. Arrthymias, Hypertension, headaches, liver malfunction, hair loss, anemia, arthritis, blockage of Nerve conduction in the heart, and others.
The above medications are intended to reduce the symptoms of NUD and reduce any pain associated with it, but end up causing more GI problems and further cover up the causes of the indigestion.
There are several supplements and medications, listed below, that can worsen the symptoms of GERD and may also negatively effect NUD (11).

• Large doses of vitamin C
• Potassium supplements
• White willow bark
• Calcium channel blockers for high blood pressure
• Certain antibiotics
• Red yeast rice
• Fosamax
• NSAIDS (Motrin, Aleve, Nuprin, Orudis)
• Theophylline
• Glucosamine
• Fish oil capsules
• Aspirin, which can also affect the stomach lining directly.
  

The health and proper function of the stomach is dependant on the balance of the defensive factors (mucin secretion, cellular mucus, bicarbonate secretion, mucosal blood flow, and cell turnover), and the aggressive factors (hydrochloric acid, pepsin, H. pylori, bile salts) (12). The role of the defensive factors is gaining importance over simply reducing the aggressive factors. With more evidence of adverse effects of the various drugs more research is being done with herbs to find new compounds to aid in ulcer treatment without the side effects, which may also prove beneficial in treating NUD. In a review of anti-ulcer drugs of Ayurvedaⁱ, authors R.K. Goel and K. Sairam listed the commonly used herbs of Ayurveda and the studies with various herbal extracts and their use in ulcer treatment. The extracts used were fresh juice, water decoction, ethanolic ,methanolic , hot water, acetone, chloroform, and petroleum ether extracts. For the following herbs they were extracted from one of the first five methods: ashwaganda, shatavari, licorice root, brahmi (Bacopa monniera), gotu kola (Centella asiatica), and amla. Aswaganda showed anti-stress activity which wasn't specified. The other herbs had no effect on the acid-pepsin secretion but an increase in the defensive factors of mucin secretion and the life span of the mucosal cells. Shilajit had a per se effect of both reducing acid-pepsin secretion and increase in mucin secretion (13). Several anti-ulcer compounds have been isolated from ginger and studies have shown that ginger increases gastrointestinal propulsion (14). In the conclusion of the review the emphasis was on standardized active constituents of the herbs and not use of the whole herb.
In a non-medication approach to better digestion there are several herbs, juices, and other compounds used to heal the stomach, or aid in digestion. Common ones are DGL – deglycyrrhizinated licorice, sulfate mucin, aloe juice, ginger tea, chamomile tea, fresh vegetable juices (cabbage, carrot, cucumber, beet), digestive enzymes, baking soda, and even Pepto-Bismol. DGL is licorice with the compound that is responsible for hypertension removed. It is known to normalize LES (lower esophageal ) pressure, increase the protective factors of the stomach, increase immunity by increase in secretin, and is antinflamatory and antioxidant (15). Of the vegetables juices cabbage is recommended more than any other to help heal the stomach lining. There are also various combinations of digestive enzymes and gladulars for those with poor digestion. Chinese and Ayurvedic herbal formulas for digestion are available through supplement suppliers with only general guidelines on their use.
In the Western view whether mainstream allopathic or a natural approach certain dietary and lifestyle changes have to be made if a person with NUD is to have an improvement in symptoms and better digestion. It is well recognized that digestion is improved if a person eats in a calm and relaxing environment. Some health care practitioners emphasize this much more than others. This and proper chewing is the beginning of proper digestion. Appropriate sized meals are important since large meals take longer to digest, distend the stomach and increase acid production, and expose the stomach longer to the aggressive factors of digestion. There is the need to eliminate or reduce offending foods such as orange juice, tomato products, other acid foods or ingredients, radishes, spicy foods, fatty foods, excessive protein, dry beans, or any other foods an individual may have symptoms with. Substances to avoid if causing problems are alcohol, tobacco, coffee, caffeineated tea, colas, Ibuprofen and other NSAIDS, aspirin, or any other medication that causes symptoms of NUD. Some healer also emphasize proper food combining or simplifying meals for easier digestion. Others are adamant about cutting out all processed foods from the diet and eliminating any foods with additives or preservatives. There is also the possibility of a food allergy in which case the offending foods will have to be identified and eliminated. This could be a lengthy and difficult process and would not usually be done unless all other changes proved unfruitful.
Food combining deserves further expounding since it is commonly referred to for digestive ailments in natural health and nutrition literature. The principal is fairly simple, don't eat foods together that don't digest well together. This won't overtax the digestive enzymes and compromise digestion. Food combining can be somewhat to very restrictive even though there is little scientific evidence that certain foods inhibit the secretion of digestive enzymes. This is not to say there has not been success to varying degrees with food combining. The most common rule is not to eat fruit, or sweets, with meals. Fruits digest sooner than other foods and they can be fermented by microorganisms before the heavier foods are digested. The resulting gas can distend the gut and cause bloating and indigestion. The gas is also toxic to the nerves and tissues, causing an inflammatory reaction that impairs normal peristaltic action (16). Also milk dose not combine well with any foods and is best eaten alone. A person would make their meals as simple as necessary to have good digestion, starting with mono meals if necessary. Other foods can be added one at a time as all previous foods are well tolerated. A person then builds a history of what they can and cannot eat and what foods they tolerate together.
In the Caraka-Samhita chapter – xv treatment of grahani dosa the digestion function, dysfunction, and treatment are discussed. This is the classical Ayurvedic approach which will be summarized, then the modern interpretation will follow. That which has an influence on the stomach and thus important in the care of NUD will be noted. All digestion is dependant upon proper functioning of the digestive fire or agni. Jatharagni (enzymes in the GI tract), bhutagnis (the elemental agnis – enzymes to transform heterogenous elements into homologous ones) dhatuagnis (enzymes for the synthesis of the seven categories of tissues) make up the 13 agnis of which jatharagni is the most important for the other depend upon its proper functioning, and is considered to be the most important sustaining factor of living beings (17). Since it resides in the GI tract it will be referred to as agni in this report.
Ingested food needs to be both delicious and wholesome to nourish the senses, the sense organs, and the rest of the body. Once ingested the food is mixed with dravas (liquids) of saliva and other fluids of the GI tract that contain the enzymes or agni . Samana vayu in its normal state will stimulate agni appropriately. Too little samana vayu and agni is low and digestion is inadequate. Too much and agni is too hot and digestion too fast which may deplete the kapha in the stomach making it more suseptable to symptoms of NUD or eventually to an ulcer. During the first stage of digestion in the mouth and stomach, or the kapha stage, the sweet taste is digested. Once the semidigested (vidagdha) food mass leaves the stomach it is sour. This sour stuff stimulates the production of pitta ⁱ(bile), and since pitta is sour it gets stimulated by sour food matter (18). Thus the appropriate amount of pitta or acid needs to be produced in the stomach for proper digestion or agni there before leaving the stomach and continuing to stimulate normal pitta and agni for optimal digestion.
Ajirna or indigestion is caused by the vitiation of agni. This is caused by the following:

• Eating too fast, over eating , or irregular eating.
• Intake of unwholesome, heavy, cold, un-unctuous, or contaminated food.
• Improper use of purgation, emetic, and oelation therapy.
• Emaciation as a result of disease.
• Living in improper country, or seasons.
• Suppression of natural urges.
  

The vitiated agni is then abnormally sour and works like poison or can be the beginning of several diseases (19). When pitta is excessive it is Amla pitta or acid gastritis a type of grahani disorder. The seat of agni is in the grahani or small intestine and stomach, which may not be used exactly the same way as in modern anatomy and physiology. The signs and symptoms of amla pitta are indigestion, mental fatigue, nausea, sour and bitter belching, and heartburn. Other pitta symptoms in the digestive system and elsewhere are yellow tongue coating, red tongue, loose stools, and anger. High vata will have less acid and burning and will have a more static or nervous stomach. Other high vata symptoms in the digestive system are gas or belching, bloating, constipation, erratic appetite, a brownish and dry tongue coating, and nervousness or anxiety. There will also be pain with both conditions. High kapha will have sluggish digestion in the stomach but not likely to suffer from NUD as much as high pitta and high vata so only pitta and vata out of balance will be considered.
Agni has four different states: normal, irregular, sharp or high, and low. In the normal state a person would eat the right quality and quantity of food and there would be proper digestion, metabolism, and tissue development. This is helped with a balanced samana vayu. With any of the abnormal agnis digestion and tissue development is compromised. Sharp agni can cause depletion of tissues if not enough food is eaten. Irregular agni usually results in an under nourished individual with an under developed body as in a typical vata type person. Low agni is associated with excessive development of poorer quality tissue as in a kapha type person. Grahani (small intestine) is the site of agni and grahani and agni can be used interchangably because agni restrains (grhnati) the downward movement of undigested food and retains it until it is fully digested in the region above the unbilicus (20). Likewise food is also retained in the stomach until it is fully digested. When agni is weak food is only partly digested and there is some undigested food in the stools. Vatika grahani (caused by vitiated vata) is caused by intake of pungent, bitter, astringent, cold dry foods, not enough food, over exertion, suppression of natural urges, and excessive sexual intercourse. Vayu gets aggravated, suppresses agni, and food is not easily digested. In paittika grahani pitta is aggravated by foods that are pungent, heavy (ajirna), vidahi (cause burning sensation), sour, alkaline, etc. This aggravated pitta supresses agni. A person has foul smelling and sour belching, heartburn, anorexia, thirst, and loose stools (21). When ama becomes manifest because of the aggravated dosa in the grahani, and food is not fully digested, then emetic therapy should be given. After the amasaya (stomach including small intestine) is cleased of the ama by purgation and fasting the patient should be given a light diet and herbs that stimulate digestion (22). If pitta is aggravated then digestive stimulants that are bitter should be given along with sweet ingredients. If vata is aggravated then digestive stimulants mixed with ghee, salty, and sour items are helpful. Samana vayu in particular is regulated with medicated ghee and promotes the proper functioning of the gastric fire. If the gastric fire gets suppressed because of urdhva-vata (upward movement of vata) the patient should be given niruha and anuvasana medicated enemas (23). In the Ayurvedic view digestion in the stomach cannot be completely separated from digestion in the small intestine since the seat of agni lies mainly in the small intestine but also in the lower part of the stomach. Digestion is a continuum and the stomach and small intestine and the whole GI tract is interdependent.
Indigestion or NUD begins with eating habits and improper food choices, but most digestive disorders begin in the stomach or are first noticed there (24). The digestive problems may then continue into the rest of the GI tract. From indigestion comes ama which disrupts not only the digestive system but also the immune system and results in low energy. The two sub doshas of most concern are pachaka pitta and samana vayu. When pachaka pitta is high there is excess gastric acid and the typical symptoms of heartburn, sour belching, and other pitta symptoms in the GI tract and mind. With high samana vayu there is nervous stomach and variable appetite, digestion, and peristalsis (25). There could also be other vata symptoms in the rest of the GI tract and mind. So hyperacidity could also occur with vata and a weak digestion where the food stays too long in the stomach which is then exposed to acid after the food can no longer buffer the acid. Apana vayu could also be involved. If it is not properly flowing downward, with possible gas and constipation, then this could slow or alter digestion further up in the GI tract and indirectly affect stomach functioning and emptying. Or apana vayu could rise upward due to nervous system vata stress and negatively effect digestion (26). Low kapha may accompany high vata and there is not adequate protection for the stomach lining from the acid even if the acid is not in excess. The eating habits that lead to excess pitta and hyperacidity are eating too much, or eating foods that are too sour, spicy, or fatty, too many sweets which can also be fatty, too much alcohol, tea, or coffee, poor food combining, and too much salty foods. Eating habits that would throw vata out of balance and lead to NUD would be eating irregular meals, eating too much, eating cold, dry, or raw foods, eating too much variety at a meal, or eating foods that are hard to digest. Other eating habits that could cause NUD with anyone are eating when not hungry, eating poorly prepared or cooked foods, eating too much processed foods instead of freshly prepared foods, and eating leftovers.
In the Ayurvedic view food, eating habits, and herbs make up the treatment for NUD. For a vata person with NUD meals may have to be smaller and more frequent, regular, and generally cooked foods. A pitta person can eat three regular meals a day, more raw food, and more variety in a meal than a vata person. A vata person needs rich and moderately spicy food , while a pitta person needs less richness and spice. Each person should also take those foods that digest easily for their constitutionⁱ, or pacifying for the high dosha. Skipping a meal until the appetite comes back may be needed.
To avoid digestive difficulties the first step would be to follow Upayogasamatha - the general guidelines for healthy eating according Ayurveda (27). To begin eat in a proper place or setting. The main point is that it is calm and peaceful. The mind should also be peaceful when eating, prepared by saying grace. This is done with awareness of the sacredness of the experience and acknowledges the spirit of the food. The food should be prepared in a loving way or in a sattvic state of mind. The food is then eaten with no distractions and a calm mind including confidence that what a person is eating is perfectly fine so there is no anxiety about eating. Time is taken to chew the food properly or to an even consistency and to fully taste and enjoy the meal. The food should be warm, and moist with some richness, which stimulates digestion, is more easily digested, and is more nourishing than dry food. It could also be said that food should be freshly prepared and cooked since it would also be warm and moist and best for digestion. Foods of opposite potencies should not be eaten in equal amounts so that they cancel each other out and end up with a neutral potency that does not promote digestion. A small amount of cool spices may be included in a dal for instance but the overall spice mix would be warm for a vata digestion. Only enough liquids to aid in eating should be taken with a meal. The more liquid the meal the less other liquid is needed, and it should not be cold. A person is best eating until about 75% full, to room for the stomach to mix and digest the food. One should feel satisfied but not full. Eating in a calm manner, chewing appropriately, taking the time to eat, and being aware of eating without distractions will give one the opportunity to sense when they are satisfied but not full. It is best to rest and not do any intense mental or physical activities after eating for up to an hour if possible. If work or other strenuous activities cannot be avoided then a smaller or lighter meal might be in order. Once the meal is finished one should not eat again until they are hungry, or the previous meal is fully digested. This is usually three hours or more. If it is sooner the person may want to or need to eat larger meals. If too long a time has past the person may have eaten too large a meal or need to strengthen their agni. Eating before the previous meal is fully digested will mix ahara rasa with the new food and vitiate all three doshas (28). This will disrupt proper digestion.
Following the Upayogasamaatha will for most people alleviate their NUD or indigestion. If that is not sufficient then each person needs to follow a diet plan for their dosha as outlined above and specifically avoid foods that aggravate them. A general diet plan for vata and pitta follows (29). A diet for vata types would include fruits except dry fruits, unless well soaked, apples, pears, and melons. A large variety of vegetables can be tolerated if properly cooked and spiced if needed or with ghee. The cruciferous vegetables may not be tolerated but some may depending on the individual. Other common vegetables that may cause some indigestion are artichokes, asparagus, cucumber, green beans, potatoes, spinach, tomatoes, turnips, and zucchini. It is more important to avoid too much raw vegetables and eat cooked vegetables, and avoid mushrooms and lettuce. For grains stick to wheat, rice, and oats. For beans only mung usually. All nuts, seeds, and oils are acceptable, as is dairy except ice cream because it is too cold. Condiments are fine and can help to pique the appetite. Sweeteners should be used in moderation and best not to use refined sugar. Animal foods are nourishing and grounding for vata but consideration should be given to the karmic consequences of eating when there is no necessity to do so. For pitta types generally avoid sour, pungent, and salty foods when there is any imbalance or tendency to get out of balance. For fruits eat sweet and astringent ones like apples, dates, figs, mango, grapes, melons, pears, persimmons, and plums. Certain fruits may cause problems – citrus, strawberries, cherries, bananas, and any sour tasting or under ripe fruit. Vegetables to avoid are hot peppers, onion, garlic, radishes, etc. Others that may be a problem are beets, carrots, spinach, chard, tomatoes, and parsley. For grains basmati rice, oats, wheat, and corn are recommended. Most dry beans can be digested well except lentils. Nuts are limited for use, best are coconut and sunflower seeds. For oils coconut, sunflower, ghee, olive, and corn. For dairy, sour products – yogurt, buttermilk, aged cheeses - limit or avoid. For sweeteners all are ok except honey and molasses. No condiments are good because of the salt and or vinegar. For animal foods egg whites and white chicken meat are good (30). This is a general list to help someone dominated by a vata or pitta constitution but is not all inclusive. Each person must also be aware when they eat if a particular food or combination of foods aggravates their digestion if they are to learn to improve their digestion and health. If a person is a duel dosha, vata – pitta, then they would have to take in foods acceptable to both doshas and avoid or limit those foods that aggravate both doshas or strongly do so to either dosha. Or if one dosha is predominately out of balance then that one would take precedence over the other dosha and the secondary dosha may not need to be addressed at that time.
If a person still has NUD after following the above guidelines then digestion may be weak and proper food combining would be appropriate. The summary of proper food combining follows: (31)
Bitter green salads should be eaten at the end of the meal not the beginning since bitter taste reduces agni.
Astringent foods or tea should be taken at the end of the meal or between meals because astringent taste reduces the secretion of digestion enzymes.
Sweets are best eaten at the beginning of the meal because they are preferentially digested and will interfere with digestion if eaten later in the meal by stopping digestion at that point to digest the sweets. Sweets can also be eaten separately between meals.
When digestion is very challenged eat only one carbohydrate and only one protein at a meal, in general simplify the meal as much as needed to improve digestion.
Avoid any difficult to digest foods such as cruciferous vegetables, raw onions, fried foods especially breaded and fried foods, heavy sweets that have high fat content, and dried beans.
For NUD there is also herbal treatment for the dosha out of balance. For a high pachaka pitta cool and demulcent herbs are used. The bitter and sweet taste predominate with a cooling effect to reduce acid and also cool the liver, small intestine, and pancreas. Typical herbs are aloe gel, amalaki, barberry, cilantro, coriander, gentian, licorice, marshmallow, shatavari, and Avipattikar churna. Other spices that can be used unless pitta is very high are cumin, fennel, mint, and turmeric. Avipattikar churna is taken after meals to reduce acidity. Bitters can also be taken before meals to counter high pitta (32). Avipattikar churna : trikatu, triphala, cyperus, vidanga, cardamom, cinnamon leaf, cloves, trivit, raw sugar. Take 1-4 grams 2-3 times a day after meals with warm water.
For high vata or high samana vayu in the stomach and digestive system the types of herbs given are carminatives to calm the system and help balance digestion. Commonly used herbs are fresh ginger, cardamom, basil, fennel, cloves, and camomile. Spices are best taken with food or something sweet or demulcent to counter the dryness of the spices. Vata in the stomach is also likely to dry out the stomach lining and a demulcent would be beneficial. Since the site of accumulation for vata is in the colon, herbs for the colon may also need to be given to help reduce vata in the stomach. In that case the formula Asafoetida 8 is appropriate, to counter gas, bloating, and constipation. Triphala would also be used for constipation since it is the chief laxative in Ayurveda (33).
Another approach is to treat NUD by increasing the agni or by alleviating the indigestion. The following are modern Ayurvedic remedies (34). To rekindle agni use:
Before a meal - Fresh ginger with a little lime juice and a pinch of salt, or ginger tea.

• Garlic pwd. ¼ tsp., ½ tsp. trikatu, and a pinch of rock salt.
• One clove fresh garlic chopped with ¼ tsp. cumin pwd. a pinch of rock salt, a pinch of trikatu, and a tsp. of lime juice.
• Ayurvedic herbal wine, Draksha. Use 2 to 4 tbs with equal amount of water.
• A tea of ginger, brahmi, and chamomile (equal parts) for emotional causes
  

After a meal a tea of bay leaves with a pinch of cardamom may help to improve agni.
For indigestion there are several options:

• Fresh pineapple juice with pinch of ginger and black pepper, and ½ tsp. sugar.
• Onion juice, fresh ¼ cup, with ½ tsp. honey, and ½ tsp. black pepper.
• Fresh garlic one clove chopped with a pinch of salt and a pinch of baking soda.
• Juice of ¼ of a lime in one cup of water, add ½ tsp. baking soda and drink right away.
• This drink is for acute indigestion.
• For chronic indigestion : trikatu 1 part, chitrak 2 parts, kutki 1 part. Take ¼ tsp. before meals, with a little honey and fresh ginger juice.
• Cumin pwd. 1/3 tsp., a pinch of asafetida, and a pinch of rock salt. Take with warm water.
• Chew Ajwan seed ½ tsp. with ¼ tsp. baking soda and take with warm water.
• Chew a mixture of roasted fennel, cumin, and coriander seeds ½ tsp.
• Or a tea of the above three seeds, equal amounts of each ½ tsp. per cup of water.
• Or a tea of angelica, chamomile, and comfrey equal amounts, ½ tsp. per cup.
  

The approach to nutrition is similar in the natural western and the Ayurvedic viewpoints, and there
are some differences. Both emphasis eating wholesome unprocessed foods, organic when possible, healthy eating habits, and appropriate amounts of food for normal healthy digestion. But Ayurveda has Upayogasamaatha, the guidelines for healthy eating that acknowledges all levels of our being that need nourishment and can be practiced by anyone regardless of their spiritual outlook.
In the care of NUD a western medicine approach, a natural health or nutritional approach, and an Ayurveda approach to healing have much in common but there are also some differences. The typical allopathic practitioner, usually an M.D., has extensive knowledge of human anatomy and physiology. They are trained to diagnose illness or diseases and when there is no manifest disease then there is often no protocol to follow in the care of the patient. Signs and symptoms maybe ignored assuming they will naturally abate, while not looking further for the causes. The patient maybe pacified with medication and the M.D. may feel it can do no harm. This is a narrow version of allopathic health care but it is typical of acute care medicine with the administration of only standardized pharmacological medications for any ailment the standard. At the other end of the spectrum M.D. and natural care practitioners are practicing medicine without medicine, using only supplements, herbals, extracts, enzymes, and an increasing number of what are considered natural products with little or no side effects. More time and care is taken with the patient to discover the underlying cause of the problem the patient presents with and not just focusing on symptoms. In acute care medicine bodily systems are separated while in a holistic view the body is integrated, and the approach to health is preventative or even to optimize health. Ayurveda's goal is to keep the body and mind healthy and to guide one on their path in life. It can touch every aspect of a person's life, and is intended to as a person is ready to let Ayurveda into their body, mind, and inner life. Comparing just the physical health aspect of each approach Ayurveda is similar to the holistic form of health care that treats each individual as an individual, with natural healing methods in assessment, diagnosis, nutrition, herbs and supplements, and other therapies. Ayurveda differs in that it is a fully integrated system consistent throughout the care of the client. The principals and therapies are in harmony with each other and support each other in the healing of the patient. In holistic care of NUD a less specific approach is used. Though a person is treated as an individual some may be given similar care of NUD though their constitutions are different. Though there is the attempt to treat the whole person and as an individual there is still a temptation to treat the symptoms or the disorder and not the imbalance that caused the symptoms. Holistic care has the benefits of extensive knowledge of the human body from medical school and research, a vast array of newer diagnostic tests that are useful in discovering underlying causes of GI symptoms, and a large choice of supplements, herbs, probiotics, natural foods, etc. for their clients. The holistic or natural or functional medicine care still has some of the analytical approach that is the hallmark of modern science and western medicine. Though the amount of knowledge and wisdom is enormous the modern systems are not completely integrated; in philosophy, principals, and practice as Ayurveda is. It might be seen as the difference of nature and science. Our bodies and minds are a part of nature and Ayurveda is natures medicine. Science is descriptive of nature and can be very knowledgeable of nature but is still separated from nature. Using science to help us heal can be very beneficial but it is still putting science first and not allowing direct communication from nature to teach and to heal directly.

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